Post by Nursing Board 101 on Aug 18, 2010 14:00:06 GMT -5

51. The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that research indicates that many peptic ulcer are the result of which of the following?a. Work-related stress b. Helicobacter pylori infection c. Diets high in fat d. A genetic defect in the gastric mucosa Ans: B – recent research has indicated that most peptic ulcers may be caused by Helicobacter pylori, which is a gram-negative bacterium. If this organism is detected through diagnostic tests, treatment of the ulcer will indicate the use of antibiotics and bismuth compounds such as Pepto-Bismol. It has not been proven that work-related stress or a genetic defect causes ulcers. Diets high in fat do not cause peptic ulcer disease.

52. A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information which nursing diagnosis would be most appropriate?a. Imbalanced nutrition: less than body requirements related to anorexia b. Disturbed sleep pattern related to epigastric pain c. Ineffective coping related to exacerbation of duodenal ulcer d. Activity intolerance related to abdominal pain Ans: B – based on the data provided, the most appropriate nursing diagnosis would be disturbed sleep pattern. A client with a duodenal ulcer commonly awakens during the night with pain. The client’s feelings of anxiety do not necessarily indicate that she is coping ineffectively.

53. The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following?a. Bland foods b. High-protein foods c. Any foods that are tolerated d. Large amounts of milk Ans: C – diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.

54. The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse’s response to observing these actions should be based on knowledge that: a. Involvement with his job will keep the client from becoming bored b. A relaxed environment will promote ulcer healing c. Not keeping up with his job will increase the client’s stress level d. Setting on the client’s behavior is an important nursing responsibility Ans: B – a relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Not keeping up with his job will probably increase the client’s stress level, but the nurse’s response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client’s behavior; clients must make the decision to make lifestyle changes.

55. A client with peptic ulcer has been instructed to avoid intense physical activity and stress. Which activity should the client incorporate into the home care plan?a. Conduct physical activity in the morning so that he can rest in the afternoon b. Have the family agree to perform the necessary yard work at home c. Give up jogging and substitute a less demanding hobby d. Incorporate periods of physical and mental rest in his daily schedule Ans: D – it would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environment. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful.

56. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?a. Before meals b. With meals c. At bedtime d. When pain occurs Ans: C – ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime.

57. A client has been taking aluminum hydroxide (Amphojel) 30 mL is six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation?a. The client has not been including enough fiber in his dietb. The client needs to increase his daily exercise c. The client is experiencing a side effect of the aluminum hydroxide d. The client has developed a gastrointestinal obstruction Ans: C – it is most likely that the client is experiencing a side effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

58. A client is taking an antacid for treatment of peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?a. “ I should take my antacid before I take my other medications.”b. “ I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.”c. “ My antacid will be most effective if I take it whenever I experience stomach pains.”d. “ It is best for me to take my antacid 1 to 3 hours after meals.”Ans: D – antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug’s action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing side effects increases. Therefore, the client should not take antacids as often as desired to control pain.

59. Which of the following would be an expected outcome for a client with peptic ulcer disease?a. The client will demonstrate appropriate use of analgesics to control pain b. The client will explain the rationale for eliminating alcohol from the diet c. The client will verbalize the importance of monitoring hemoglobin and hematocrit every 3 months d. The client will eliminate contact sports from his or her lifestyle Ans: B – alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client’s hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

60. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of potential complication?a. The client complains of a sore throat b. The client displays signs of sedation c. The client experiences a sudden increase in temperature d. The client demonstrates a lack of appetite Ans: C – the most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process.

61. The nurse is completing a health assessment of a 42-year-old woman with suspected Grave’s disease. The nurse should asses this client for: a. Anorexia b. Tachycardia c. Weight gain d. Cold skin Ans: B-grave’s disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increase metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

62. A female client with thyrotoxicosis would probably report which changes related to the menstrual cycle during initial assessment?a. Dysmenorrhea b. Metrorrhagia c. Oligomenorrhea d. Menorrhagia Ans: C- A change in menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism.

63. Prophylthiouracil (PTU) is prescribed for a client with Grave’s disease to decrease circulating thyroid hormone. The nurse should teach the client to immediately report which of the following signs and symptoms?a. Sore throat b. Painful, excessive menstruation c. Constipation d. Increased urine output Ans: A- The most serious side effect of PTU are leukopenia and agranulocytosis, which usually occur within the first three months of treatment. The client should be thought to promptly report to the health care provider any signs and symptoms of infection, such as sore throat and fever. Any client complaining of sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be held until the result are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

64. A client with thyrotoxicosis says to the nurse, “ I am so irritable. I am having problems at work because I lose my temper very easily.” Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?a. “ Your behavior is caused by temporary confusion brought on by your illness.” b. “ Your behavior is caused by the excess thyroid hormone in your system.”c. “ Your behavior is caused by your worrying about the seriousness of your illness.”d. “ Your behavior is caused by the stress of trying to manage a career and cope with illness.”Ans: B- A typical signs of thyrotoxicosis is irritability caused by the high level of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed.

Ans; D- Elevated serum concentrations of thyroid hormones and suppressed serum TSH are the features of thyrotoxicosis. Decreased or absent serum TSH is very accurate indicator of thyrotoxicosis. Increase level of circulating thyroid hormones cause the feedback mechanism to the brain to suppress TSH secretion.

66. The nurse should teach the client to prevent corneal irritation from mild exophthalmos by: a. Massaging the eyes at regular intervals b. Instilling an ophthalmic anesthetic as ordered c. Wearing dark-colored glasses d. Covering both eyes with moistened gauze pads Ans C- Treatment of mild opthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eye from corneal irritation. Treatment of opthalmopathy should be performed in consultation with an opthalmologist. Massaging the eye will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not satisfactory nursing measure to protect the eyes of the client with exopthalmus because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exopthalmus, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased.

67. A client with Grave’s disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works?a. “ The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy.”b. “ The radioactive iodine reduces uptake of thyroxine and thereby improves your condition.”c. “ The radioactive iodine lowers the levels of thyroid hormones by slowing your body’s production of them.”d. “ The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced.”Ans: D- Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. Use of RAI is often recommended for many clients with Grave’s disease, especially the elderly. The treatment results in “ medical thyroidectomy”. RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving the RAI is the destruction of thyroid follicular cells. It is possible to slow the production of the thyroid hormones with RAI.

68. Which of the following nursing diagnoses would most likely be appropriate for a client with Grave’s disease performing self-care after treatment with RAI in the form of sodium iodide 131I?a. Risk for injury related to altered level of consciousnessb. Ineffective breathing pattern related to effects of radioactive iodine c. Total self-care deficit related to the need for immobilization after RAI therapy d. Risk for ineffective therapeutic regimen related to lack of knowledge about disease management Ans: D- management of the disease process is priority for the client who has undergone RAI therapy with sodium iodide 131I. Signs of hyperthyroidism usually persist for 1 to 2 months and may be still present for up to 1 year until thyroid hormone production stops. Permanent hypothyroidism is the major complication of radioactive treatment. At that time, the client will be able to recognize symptoms of hypothyroidism. Changes in level of consciousness or breathing pattern are not expected. The client does not need to be immobilized after RAI treatment.

69. After treatment with RAI in the form of sodium iodide 131I, the nurse teaches the client to: a. Monitor signs and symptoms of hyperthyroidism b. Rest for 1 week to prevent complications of the medication c. Take thyroxine replacement of the remainder of the client’s life d. Assess for hypertension and tachycardia resulting from altered activity Ans: C- The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism.

70. A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps; a. Slow progression of exophthalmos b. Reduce the vascularity of the thyroid gland c. Decrease the body’s ability to store thyroxine d. Increase the body’s ability to excrete thyroxine Ans: B- SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that present a hazard during surgery. Preparation of the client or surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exopthalmus, and it does not decrease the body’s ability to store thyroxine or increase the body’s ability to excrete thyroxin.

71. Which of the following measures is most recommended when preparing SSKI for administration?a. Pour the solution over ice chips b. Mix the solution with water, milk or fruit d. Dilute the solution with water, milk fruit juice and have the client drink it with a straw Disguise the solution in a pureed fruit or vegetableAns: C- SSKI should be diluted well in milk, water, juice, or carbonated beverage before administration to disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a purée would put the SSKI in contact with the teeth.

72. The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this primarily to monitor for signs of which of the following?a. Internal hemorrhage b. Decreasing level of consciousness c. Laryngeal nerve damage d. Upper airway obstruction Ans: C- Laryngeal nerve damage is not a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps to Asses for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhages are detected by changes in vital signs. The client’s level; of consciousness can be partially assed by asking her to speak, but it is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate pattern.

73. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: a. Begin total parenteral nutrition b. Start a cutdown infusion c. Administer tube feedings d. Perform a tracheostomy Ans: D- Equipment for an emergency tracheostomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set , oxygen and suction equipment, and suture removal set ( for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Intravenous infusion via a cutdown is not expected possible treatment for thyroidectomy. Tube feedings are not anticipated emergency care.

74. Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?a. Pains in the joints of the hands and feet b. Tingling in the fingers c. Bleeding on the back of the dressing d. Tension on the suture line Ans: B- Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of tetany is numbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur from 1 to 7 days postoperatively. Late signs of tetany include seizures, contraction of the glottis, and respiratory obstruction. Pains in the joints of the hands and feet are not early symptoms of tetany. Bleeding on the back of the dressing is related to possible incisional complications. Tension on the suture line may indicate swelling, infection, or internal bleeding, but it is not related to tetany.

75. Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?a. Sodium phosphate b. Calcium gluconate c. Echothiophate iodide d. Sodium bicarbonate Ans: B- The client with tetany is suffering from hypocalcemia, which is treated by administering an intravenous preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until parathyroid function returns. Sodium phosphate is a laxative. Echothiopate iodide is an eye preparation used as miotic for antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid.

77. Appropriate nursing diagnoses for a client with hypothyroidism would probably include which of the following?a. Risk for injury (corneal abrasion) related to incomplete closure of eyelid b. Imbalanced nutrition: less than body requirements related to hypermetabolism c. Deficient fluid volume related to diarrhea d. Activity intolerance related to fatigue associated with the disorder Ans: D- A major problem for the person with hypothyroidism is fatigue. Other sign and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism.

78. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: a. The effects of thyroid hormone replacement therapy and will diminish over time b. Related to the thyroid hormone replacement therapy and will not diminish over time c. A normal part of having a chronic illness d. Most likely related to low thyroid hormone levels and will improve with treatment Ans: D- Hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking the thyroid hormone and TSH levels. This client needs to know that these feelings may be related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does not cause depression. Depression may accompany chronic illness, but it is not “ normal.”

79. A 55-year-old male client has recently been diagnosed with type 2 diabetes mellitus (DM) and is prescribed the sulfonylurea compound tolbutamide (Orinase). He is concerned about the diagnosis and says he knows nothing about diabetes. The nurse determines that the client needs teaching and support. The nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?a. Potentiating the action of insulin b. Lowering the renal threshold of glucose c. Stimulating insulin release from functioning beta cells in the pancreas d. Combining with glucose to render it inert. Ans: C – oral hypoglycemic agents of the sulfonylurea group, such as tolbutamide (Orinase),lower the blood glucose level by stimulating functioning beta cells in the pancreas to release insulin. These agents also increase insulin’s ability to bind to the body’s cells. They may also act to increase the number of insulin receptors in the body. Tolbutamide does not potentiate the action of insulin. Tolbutamide does not lower the renal threshold of glucose, which would not be a factor in the treatment of diabetes in any case. Tolbutamide does not combine with glucose to render it inert.

80. When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following: a. Avoid going barefoot b. Buy shoes a half size larger c. Cut toenails at angles d. Use heating pads for sore throat Ans: A – the client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn, because they will cause blister that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because at risk for burns to insensitivity to temperature.

81. A client with DM asks the nurse to recommend something to remove corns from his toes. The nurse should advise him to: a. Apply a high-quality corn plaster to the area b. Consult his physician or podiatrist about removing the corns c. Apply iodine to the corns before peeling them offd. Soak his feet in borax solution to peel off the corns Ans: B – a client with diabetes should be advised to consult a physician or podiatrist for corn removal because of the danger or traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a physician or podiatrist.

82. A client with DM presents to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client’s hands. The client says, “ I’m so clumsy. I’m always cutting my finger cooking or burning myself on the iron.” Which of the following responses by the nurse would be most appropriate?a. “ Wash all wounds in isopropyl alcohol.”b. “ Keep all cuts clean and covered.”c. “ Why don’t you have your children to do the cooking and ironing?”d. “ You really should be fine as long as you take your daily medication.”Ans: B – proper and careful first-aid treatment is important when a client with diabetes has a skin cut or laceration. The skin should be kept supple and as free or organisms as possible. Washing and bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the skin. Having the children help is an unrealistic suggestion and does not educate the client about proper care of wounds. Tight control of blood glucose levels through adherence to the medication regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored.

83. The client with DM says, “ If I could just avoid what you call carbohydrates in my diet, I guess I would be okay.” The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following?a. Carbohydrates only b. Fats and carbohydrates only c. Protein and carbohydrates only d. Proteins, fats, and carbohydrates Ans: D – DM is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client’s diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamin.

84. A client with type 1 DM is admitted to the emergency department. Which of the following respiratory patterns requires immediate action?a. Deep, rapid respirations with long expirations b. Shallow respirations alternating with long expirations c. Regular depth of respirations with frequent pauses d. Short expirations and inspirations Ans: A – deep, rapid respirations with long expirations is indicative of Kussmaul’s respiration, which occurs in metabolic acidosis. The respirations increase in rate and depth, and the breath has a “ fruity” or acetone-like odor. This breathing pattern is the body’s attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.

85. The nurse should caution the client with DM who is taking a sulfonylurea medication that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following?a. Hypokalemia b. Hyperkalemia c. Hypocalcemia d. Disulfiram (Antabuse)-like symptoms Ans: D – a client with diabetes who takes any first-or second-generation sulfonylurea should be advised to avoid alcohol intake. Sulfonylurea in combination with alcohol can cause serious reactions of disulfiram (Antabuse)-like reactions including flushing, angina, palpitations, and vertigo. Serious reactions such as seizures and possibly death may also occur. Hypokalemia, Hyperkalemia, and hypocalcemia do not result from taking sulfonylureas in combination with alcohol.

86. A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which of the following statements would demonstrate to the nurse that the client understands the instructions?a) “ I should limit the use of the inhaler to early morning and bedtime use.”b) “ It is important to not shake the canister, because that can damage the spray device.”c) “ I should hold one nostril closed while I insert the spray into the other nostril.”d) “ The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.”Ans: C- When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the nostril to ensure the best inhalation of the spray. Use of inhaler is not limited to mornings and bedtime. The canister should be taken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize the inhalation of medication.

87. Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection?a) The client maintains a fluid intake of 800 mL every 24 hours b) The client experiences chills only once a day c) The client coughs productively without chest discomfort d) The client experiences less nasal obstruction and discharge Ans: D- A client recovering from upper respiratory tract infection should report decreasing or no nasal discharge or obstruction. Daily fluid intake should be increased to more than 1 L every 24 hours to liquefy secretions. The temperature should be below 100ºF (37.8ºC) with no chills or diaphoresis. A productive cough with chest pain indicates pulmonary infection, not an upper respiratory tract infection.

88. The nurse teaches the client how to instill nasal drops. Which of the following techniques is correct?a) The client uses sterile technique when handling the dropper b) The client blows the nose gently before instilling drops c) The client uses a new dropper for each installation d) The client sits in a semi-fowler’s position with the head tilted forward after administration of the drops Ans: B- The client should blow the nose before instilling nose drops. Instilling nose drops is a clean technique. The dropper should be cleaned after each administration, but it does not to be changed. The client should assume a position that will allow the medication to reach the desired area; this is usually supine position.

89. A client with acute sinusitis is examined in an ambulatory clinic. The nurse can anticipate the use of which of the following medications in the client’s treatment plan?a) Antibiotics b) Antihistamines c) Bronchodilators d) Oral corticosteroids Ans: A- The plan of care for a client who has acute sinusitis includes antibiotics to treat the bacterial infection. In addition the nasal cortecosteroids and decongestants are frequently ordered to decrease mucosal inflammation and edema. Nasal cortecosteroids are preferred to oral cortecosteroids because they do not produce systematic side effects when used as prescribed. Anti histamines can promote an increase in secretion viscosity and continued symptoms; they should be avoided. Bronchodilators are ineffective in sinusitis.

90. The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?a) Avoid the use of caffeinated beverages b) Perform postural drainage every day c) Take hot showers twice daily d) Report a temperature of 102oF (38.9oC) or higherAns: C- The client with chronic sinusitis should be instructed to take hot showers in the morning and evening to promote drainage of secretions. There is no need to limit caffeine intake. Performing postural drainage will inhibit removal of secretions, not promote it. Clients should elevate the head of the bed to promote drainage. Client should report all temperature higher than 100.4ºF (38ºC), because a temperature that is high can indicate infection.

91. Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination?a) A 60-year-old man with a hiatal hernia b) A 36-year-old woman with three children c) A 50-year-old woman caring for a spouse with cancer d) A 60-year-old woman with osteoarthritis Ans: C- Individuals who are household members or home care providers for high-risk individuals are high priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for the husband with a cancer has the highest priority of the clients described, because her husband is likely to be immunocompromised and particularly susceptible to flu. A healthy 60-year old man or 36-year-old woman is not in a high priority category for influenza vaccination than a home care provider.

92. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?a) “ Use your nasal decongestant spray regularly to help clear your nasal passages.”b) “ Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”c) “ It is important to increase you activity. A daily brisk walk will help promote drainage.”d) “ Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks.”Ans: D- it is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the client’s symptoms; in fact walking outdoors may increase them if the client is allergic to pollen.

93. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?a) It is likely that the client is developing a secondary bacterial pneumonia. b) The assessment findings are consistent with influenza and are to be expected c) The client is getting dehydrated and needs to increase her fluid intake to decrease secretions d) The client has not been taking her decongestants and bronchodilators as prescribedAns: A- pneumonia is the most common complication of influenza, especially in the elderly. The development of purulent cough and crackles may be an indicative of bacterial infection and are consistent with diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.

94. Guaifenesin 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?a) 5.0 mL b) 7.5 mL c) 9.5 mLd) 10.0 mLAns: B- 300 mg/x= 200 mg/ 5 ml; x= 7.5 mL

95. Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible side effect of this drug?a) Constipation b) Bradycardia c) Diplopia d) RestlessnessAns:D Side effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the central nervous system (CNS) The most common CNS side effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side effects include tachycardia, hypertension, palpitations and arrhythmias. Constipation and diplopia are not side effects of pseudoephedrine. Tachycardia and not bradycardia is a side effect of pseudoephedrine.

96. A 27-year-old woman has had elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact?a) Complaints of nausea b) Repeated swallowing c) Increased respiratory rate d) Increased pain Ans: B- Because of the dense nasal packing, bleeding may not be apparent through the nasal drip pad. Instead the blood may run down the throat, causing the client to swallow frequently. The back of the throat, where blood will be apparent, can be assessed with a flashlight. An accumulation of blood in the stomach can cause nausea and vomiting, but nausea would not be the initial indicator of bleeding.

97. A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client?a) Avoid activities that elicit the valsalva maneuverb) Take aspirin to control nasal discomfort c) Avoid brushing the teeth until the nasal packing is removed d) Apply heat to the nasal area to control swelling Ans: A- The client should be instructed to avoid any activities that cause Valsalva’s maneuver (eg. Constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture line. The client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client’s appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.98. Which of the following statements would indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery?a) “ I should not shower until my packing is removed.”b) “ I will take stool softeners and modify my diet to prevent constipation.”c) “ Coughing every 2 hours is important to prevent respiratory complications.”d) “ It is important to blow my nose each day to remove the dried secretions.”Ans: B- Constipation can cause straining during defecation, which can induce bleeding. Showering is not contraindicated. The client should take measure to prevent coughing, which can cause bleeding. The client should avoid blowing her nose for 48 hours after the packing is removed. Thereafter, she should blow her nose gently, using the open-mouth technique to minimize bleeding in the surgical area.

99. The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included?a) After surgery, nasal packing will be place for 7 to 10 days b) Normal saline dose drops will need to be administered preoperatively c) The results of the surgery will be immediately obvious postoperatively d) Aspirin-containing medications should not be taken for 2 weeks before surgery Ans: D- Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline drops are not routinely administered pre-operatively. The result of surgery will not be obvious immediately after surgery because of edema and ecchymosis.

100. Which of the following assessments would be a priority immediately after nasal surgery?a) Assessing the client’s pain b) Inspecting for periorbital ecchymosis c) Assessing respiratory status d) Measuring intake and output Ans: C- Immediately after nasal surgery, ineffective breathing patterns may develop as a result of nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assessing airway obstruction is a priority Assessing for pain is important, but it is not as a high priority as assessment of the airways. It is too early to detect ecchymosis. Measuring intake and output is not typically a priority nursing assessment after nasal surgery.